Order an Exam | XR Mobile X-Ray Requisition Form

Section 1

Requesting Physician

Physician Name *

NPI # *

Phone *

Fax

Email *

Order Date *

Digital Signature (Type Full Name) *

By typing your name above, you certify that this test is medically necessary for the diagnosis and treatment of this patient, and that the patient has physical limitations preventing them from receiving the exam outside the home or facility.

Section 2

Patient Information

Patient Full Name *

Date of Birth *

Sex *

SSN (Last 4)

Room #

Facility Name *

Address *

City *

State *

ZIP *

Section 3

Insurance Information

Primary Insurance

Insurance Name

Insurance ID #

Secondary Insurance

Insurance Name

Insurance ID #

Section 4

X-Ray Studies

Check all that apply. For paired anatomy, indicate L (Left), R (Right), or both.

Head & Neck

Skull70250 Facial Bones 3 View70150 Orbits 4 View70200 Nasal Bones 3 View70160 Mandible L R 70100 Sinuses70210

Other Head/Neck Study

Chest & Abdomen

Chest 1 View71045 Chest AP / LAT 2 View71046 Ribs 2 View L R 71100 Ribs Unilateral + Chest PA 3 View71101 Ribs Bilateral + Chest PA 4 View71111 Abdominal KUB 1 View74018 Abdominal Flat & Upright 2 View74020

Spine & Pelvis

Cervical Spine AP / LAT72040 Thoracic Spine 3 View72072 Lumbar Spine 2–3 View72100 Pelvis 1–2 View72170 Sacrum / Coccyx72220

Upper Extremities (L / R)

Lower Extremities (L / R)

Section 5

Ultrasound Studies

Check all that apply.

Head & Neck

Neck Soft Tissue Thyroid76536

Abdomen

Complete Abdominal * Aorta / AAA76706 Renal76770 Bladder **76770

* Abdominal ultrasounds require the patient to NOT eat or drink for at least 6 hours prior to the exam.

Breast

Breast L R Bilat 76641 / 76642

Pelvic

Soft Tissue Groin Testicular / Scrotum76870 Pelvic Non-OB **76856 Pelvic **76857

** Pelvic ultrasounds require the patient to have a full urinary bladder.

Vascular Studies

Rule out DVT

Section 6

Cardiac Studies

EKG93000 Holter Monitor 24 HR93228 Pacemaker Check93293 Echocardiogram93306

Section 7

Reason for Study

Clinical Reason / Symptoms *

Required for billing and to give the radiologist clinical context.

Additional Notes / Special Instructions

Mobile Exam Order Form

Requesting Physician

Patient Information

Insurance Information

Primary Insurance

Secondary Insurance

X-Ray Studies

Head & Neck

Chest & Abdomen

Spine & Pelvis

Upper Extremities (L / R)

Lower Extremities (L / R)

Ultrasound Studies

Head & Neck

Abdomen

Breast

Pelvic

Vascular Studies

Cardiac Studies

Reason for Study

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Order Received